阻挡钉加强交锁髓内钉固定长骨干骺端骨折的疗效观察

自2000年1月～2002年6月,应用交锁髓内钉加用阻挡螺钉技术治疗胫骨、股骨远端骨折12例,取得较好的疗效。报告如下。1 临床资料1.1 一般资料 本组12例中,男10例,女4例,年龄18～68岁,其中胫骨远端骨折8例,股骨远端骨折4例,远骨     

骨盆骨折动脉损伤的影像学研究及临床治疗

目的探讨骨盆骨折动脉损伤的影像学特点及动脉栓塞的方法。方法自1999年1月至2005年6月，收治因骨盆骨折致血流动力学不稳患者60例。男42例，女18例；年龄21—52岁，平均34．5岁。交通伤32例，压砸伤13例，坠落伤9例，其他伤6例。入院时均处于休克状态，常规摄骨盆后前位、出口位及入口位x线片。在抗休克治疗同时，行髂动脉造影。结果后环骨折25例，损伤血管64支；前环骨折13例，损伤血管17支；髋臼骨折6例，损伤血管12支；混合骨折16例，损伤血管36支。1例髂总动脉血栓形成行人造血管移植；4例髂外动脉损伤，3例血栓形成（1例行手术取栓，1例行溶栓再通术，1例未处理），1例破裂行修复术；50例为髂内动脉及其分支损伤出血，行动脉栓塞；5例未发现明显血管损伤。3例死亡。结论根据骨盆骨折x线表现可预测血管损伤类型，后环骨折容易引起臀上动脉、骶外侧动脉及髂腰动脉损伤，前环骨折易损伤闭孔动脉，最易损伤的动脉是臀上动脉。栓塞出血动脉的断端及其吻合支是最佳的治疗方法。     

儿童陈旧性孟氏骨折治疗的新方法：附16例报告

应用自行设计的钢丝套环法治疗陈旧性孟氏骨折１６例。取得了良好的效果。用０．８ｍｍ直径钢丝套住复位后的桡骨颈并固定在尺骨近端，重新修复环状韧带。尺骨近端骨折用钢板或髓内钉固定，术后４８小时可练习肘关节伸屈及前臂旋转活动。待修复后的环状韧带愈后拔出钢丝。该方法较传统的方法简便、固定有效、复位满意，大部分患者术后４８小时即可进行关节活动，有效地防止关节粘加和后桡骨小头再脱位，且不影响桡骨小头发育。经随访     

高能灌注液对断肢再植术后肢体保护作用的实验研究

[目的]探讨高能灌注液对断肢再植术后肢体保护作用。[方法]选用健康SD兔18只,根据干预方法的不同将18只SD兔随机分为3组,每组6只,为空白对照组、缺血再灌注组(IR组)、高能灌注液保护组(高能组)。建立左后离断肢体模型,高能组于缺血时、再灌注时给予高能灌注液灌注,于2、4、8、12 h于胫骨前肌取材,测定骨骼肌超氧化物歧化酶(SOD)、丙二醛(MDA)、髓过氧化物酶(MPO)、Na+-K+-ATP酶、Ca2+-ATP酶,湿重/干重比值,光镜下观察大体结构变化。[结果]各项指标经过统计学处理后,发现三组间有着显著性差异(P<0.05),高能组明显优于缺血再灌注组,并且随着时间的延长差异更加明显。[结论]高能灌注液能够有效地预防骨骼肌的缺血再灌注损伤,从不同环节进行多种药物联合应用是对断肢再植术后肢体保护的有效方法。     

骨桥蛋白对Ⅰ型神经纤维瘤病小鼠破骨细胞功能的影响

Ⅰ型神经纤维瘤病( NFI)患者有明显的骨质疏松和骨量减少[1-2],我们报道了神经纤维瘤病破骨细胞功能增强是引起骨改变的机制之一[3].骨桥蛋白(OPN)具有细胞因子和基质蛋白两种性质,能影响骨代谢平衡,造成骨质疏松.我们应用Nf1基因杂合型小鼠模型,研究外源性骨桥蛋白对其破骨细胞生物学功能的影响,并与同源野生型小鼠破骨细胞功能进行统计学比较.     

难复位性股骨颈骨折的概念提出与治疗

目的 提出难复位性股骨颈骨折的概念,并探讨其分型与治疗方法.方法 对2006年1月至2008年12月收治的519例移位型股骨颈骨折患者进行前瞻性研究,男241例,女278例;年龄21 ～ 66岁,平均54.9岁;左侧295例,右侧224例.所有患者首先尝试牵引闭合复位,若经3次整复骨折不能达到理想复位效果,则认为属于难复位性股骨颈骨折,改用股骨头干三维互动复位技术复位,并采用3枚空心钉固定.分析难复位性股骨颈骨折的特点并对其进行分型,评价股骨头干三维互动复位技术的临床疗效.结果 共有31例(6.0％)难复位性股骨颈骨折,男20例,女11例;年龄21 ～58岁,平均39.6岁;均为GardenⅣ型骨折.均采用股骨头干三维互动复位技术复位成功,28例骨折复位质量达Garden指数Ⅰ级,3例达Garden指数Ⅱ级.根据X线片及CT影像学特点,难复位性股骨颈骨折可分为3型:Ⅰ型5例(16.1％):骨折线为斜形,近端骨折片呈“鹰嘴”状嵌插入骨折远端;Ⅱ型17例(54.8％):骨折线不规则,骨折远端外旋并嵌插入近端;Ⅲ型9例(29.0％):骨折端完全移位,股骨头和股骨干之间有分离,股骨头成漂浮状态,旋转移位较大.29例患者术后获2～4年(平均3.3年)随访,骨折均获骨性愈合,愈合时间为16～24周(平均20.1周).3例发生股骨头坏死,其中Ⅱ型l例,Ⅲ型2例.结论 难复位性股骨颈骨折可分为3型,采用股骨头干三维互动复位技术复位、3枚空心钉固定可获得较好的临床疗效.     

隐匿性血管损伤的临床特点与诊疗策略

目的 探讨临床骨科中隐匿性血管损伤的临床特点、诊断与治疗,以期提高对此类损伤的认识和临床诊治效率.方法 2003年3月至2010年10月共收治649例血管损伤患者,其中隐匿性血管损伤50例(7.7%),男42例,女8例;年龄13～66岁,平均34.0岁.血管损伤类型:静脉损伤1例,动脉损伤42例,动、静脉同时损伤7例.根据张英泽等提出的肢体动脉编码和损伤分型:A型14例,B型20例,C型16例.初始损伤至诊断时间平均为43.4 d(2～337 d),表现为肢体缺血、骨筋膜室综合征、血肿或假性动脉瘤、出血、神绛受压等征象.辅助检查包括:彩色多普勒超声17例,CT血管造影7例,X线血管造影25例.手术治疗43例,包括血管修补、直接吻合、自体静脉移植、结扎及截肢,其中2例术后行血液滤过治疗;内科治疗3例;介入栓塞治疗4例.结果 4例患者截肢后伤口愈合良好,无并发症发生;其余46例患者出院时患肢皮肤温度、颜色均恢复正常,远端动脉搏动存在,平均随访6.7个月(1～42个月),患肢血运良好.结论临床工作中的隐匿性血管损伤并非少见,其临床表现具有延迟出现、多种多样及不典型的特点.诊断方法应优先选择血管造影.治疗以手术为主,酌情采用血管内介入治疗和血液滤过治疗.

Abstract：

Objective To investigate clinical characteristics, diagnosis and treatment of insidious vascular injuries in orthopaedic cases. Methods Between March 2003 and October 2010, we treated 649 cases of orthopedic and vascular injuries, 50 (7. 7% ) of which were identified as insidious injuries. They were 42 men and 8 women, aged from 13 to 66 years (average, 34. 0 years). The insidious injury affected the vein in one case, the artery in 42 cases and both in 7 cases. The vascular injuries were categorized as type A (14 cases), type B (20 cases) and type C (16 cases) according to the classification system proposed by Zhang Ying-ze. The diagnoses were made after an average of 43. 4 days from primary injuries, with the assistance of color Doppler ultrasound in 17 cases, CT angiography in 7 and X-ray angiography in 25. Clinical manifestations included limb ischemia, compartment syndrome, hematoma or pseudoaneurysm, hemorrhage and nerve entrapment. Forty-three patients were treated by a variety of surgical options, such as angiorrhaphy, anastomosis, transplantation of autogenous venous graft, ligation and amputation. Among them, hemofiltration was performed in 2 cases as adjuvant therapy. Endovascular embolization was performed in 4 cases and conservative treatment in the other 3. Results Forty-six patients had their limbs salvaged, with normal temperature and color of the skin and existence of distal arterial pulses at discharge from hospital. The other 4 patients had to sustain amputation. An average follow-up of 6. 7 months (from one to 42 months) revealed that all the affected limbs regained normal blood circulation. Conclusions The insidious presentations and atypical clinical manifestations make diagnosis of insidious vascular injury very difficult. We recommend angiography as the first step in diagnosis. Surgical approaches should be considered as the main treatment choice, and hemopurification can be used as adjuvant therapy if necessary. In some cases, endovascular intervention may be faster and safer.     

应用可调式导向器辅助髋关节置换股骨颈截骨23例

全髋关节置换术（total hip arthroplasty,THA）是目前治疗髋关节疾病,改善髋关节畸形,减轻疼痛和保存关节功能最有效的手术方式.但是,随着髋关节置换手术的广泛应用,术后出现的并发症也逐渐增多.有研究[1]表明,下肢不等长（leg length discrepancy,LLD）是THA术后较常见的并发症,同时LLD也是影响患者步态和功能恢复的主要原因,是患者对术后效果不满意或引起诉讼的主要原因之一.THA术前模板测量计划股骨颈截骨高度和假体置入位置是公认的防范LLD发生的有效办法.目前在临床中凭经验进行股骨颈截骨易造成截骨高度与计划的数值差异,从而影响假体型号的选择,最终导致LLD的发生.为了使手术中能更精确地截骨,笔者设计了可调式髋关节置换股骨颈截骨导向器,自2013年2月至今在23例髋关节置换手术中临床应用,现报告如下.     

Ⅰ期经皮克氏针撬拨复位内固定治疗开放性跟骨骨折

开放性跟骨骨折比较少见,约占全部跟骨骨折的8．5％-10．0％。国内文献中有关开放性跟骨骨折的报道比较少,国外文献有关开放跟骨骨折的文献近年来越来越多,但尚未明确其相应的治疗规范。开放性跟骨骨折多为粉碎性,常常波及距下关节面,加之软组织损伤较重,治疗较为困难,功能恢复常不理想。其治疗的关键是避免软组织感染及并发症,最大程度恢复后足稳定性及功能。我科自2012年2月-2013年4月采用Ⅰ期克氏针内固定治疗12例开放性跟骨骨折患者,疗效满意,报告如下。     

Biomechanical comparison of gourd-shaped LCP versus LCP for fixation of comminuted tibial shaft fracture

The purpose of this study was to compare monotonic biomechanical properties of gourd-shaped LCP fixation with LCP fixation of human tibial shaft in gap fracture mode. Twenty paired fresh cadaveric human tibias were randomly divided into 4 groups (5 pairs each): (1) axial loading single cycle to failure testing, (2) torsion single cycle to failure testing, (3) 4-point bending single cycle to failure testing, and (4) dynamic 4-point bending testing. A 7-hole 4.5 mm gourd-shaped LCP was secured on the anteromedial surface of 1 randomly selected bone from each pair, respectively, using 6 locking screws in the 1st, 2nd, 3rd, 5th, 6th and 7th hole with the middle hole unfilled and just located at the mid-diaphysis of the tibia. A 7-hole 4.5 mm LCP was secured on the other bone with the same method. Standard AO/ASIF techniques were used. After fixation finished, a 10 mm gap in the mid-diaphysis of tibia was created, centrally located at the unfilled hole. The axial, torsional, and bending stiffness and failure strengths were calculated from the collected data in static testings and statistically compared using paired Student’s t-test. The 4-point bending fatigue lives of the two constructs were calculated from the dynamic testing data and also statistically compared using paired Student’s t-test. Failure modes were recorded and visually analyzed. P<0.05 was considered significant. Results showed that the axial, torsional and bending stiffness of gourd-shaped LCP construct was greater (4%, 19%, 12%, respectively, P<0.05) than that of the LCP construct, and the axial, torsional and bending failure strengths of gourd-shaped LCP construct were stronger (10%, 46%, 29%, respectively, P<0.05) than those of the LCP construct. Both constructs failed as a result of plate plastic torsional deformation. After axial loading and 4-point bending testings, LCP failed in term of an obvious deformation of bent apex just at the unfilled plate hole, while the gourd-shaped LCP failed in term of a deformation of bent arc between the 3rd and 5th holes, which indicated a more consistent stress distribution on gourd-shaped LCP. Fatigue life of gourd-shaped LCP construct was significantly greater than LCP construct (153 836±2 228 vs. 132 471±6 460 cycles, P<0.01). All constructs failed as a result of fracture of the plate through the compression hole of the unfilled combination screw hole. The biomechanical testing showed that gourd-shaped LCP can provide greater stiffness and strength, and longer fatigue life than LCP. The gourd-shaped LCP may be more advantageous mechanically and may reduce the plate breakage rate clinically.